102 SOUTH HOLDEN STREET WARRENSBURG, MO 64093

REQUEST FOR PROPOSALS COLLECTION AGENCY SERVICES ISSUE DATE OCTOBER 8, 2015

SPECIFICATIONS OF THE CITY OF WARRENSBURG REQUEST FOR PROPOSAL I.

GENERAL INFORMATION

The City of Warrensburg, Missouri (City) is soliciting proposals from debt collection agencies (Agency) to assist in the collection of delinquent City billings. To be considered in the review process, proposals must be received by 2:00 p.m. on October 23, 2015. All proposals should be directed to: The office of the City Clerk 102 South Holden Street Warrensburg, Missouri, 64093 Envelopes containing proposals are to be sealed and prominently marked: “COLLECTION AGENCY SERVICES”. Interested parties must submit one original document and one copy, or an electronic document. The decision to award collection contracts shall be based on the ability of the agency to provide adequate service of the accounts and the costs associated with that service. The award will be made as judged to be in the best interest of the City. Questions regarding the scope and/or the specifications should be addressed to Matthew Lue by E-mail: [email protected] , or Phone: 660-262-4640 The term of the contract shall be for one year. The City has the option to renew the agreement for four (4) additional one year terms at the same percentage of commission, terms and conditions with the consent of the agency. Any contract is subject to City Council approval and available funding. II.

EVALUATION PROCEDURES AND QUALIFICATIONS 1. The following instructions shall be utilized: A. Upon receipt, all proposals will be taken under advisement. The City may interview bidders to obtain an accurate understanding of each bid. Any informal, defective or irregular proposal may be rejected. All proposals shall comply with the stated specifications or noted exceptions. B. Submission of a proposal indicates acceptance by the firm of the terms and conditions contained in this request for proposal, unless clearly and specifically noted in the proposal submitted and confirmed in the contract between the City of Warrensburg, Missouri and the firm selected.

C. All proposals remain valid for sixty days to give City Council and staff adequate time for review. The City reserves the right to reject any and all proposals for any reason deemed material and to accept any proposals deemed most advantageous to the City. 2. Agency Qualifications A. Each bidder is required to submit a company overview, sample monthly reports, overview of security processes to ensure protection of any confidential information, and a sample contract for services. Also, the Agency must provide a narrative outlining the agency’s general collection process, including how the agency will successfully achieve reasonable collection targets, while balancing a heightened sensitivity of public and elected officials, and the dollar threshold where various levels of follow up occur. B. Submitted proposals must indicate how the City will be kept informed of the progress of each account placed with the agency, as well as provide a summary and detail report of all accounts. In addition, proposals must provide for the total listing of the gross amount of all collections with a separate billing for agency services rendered. C. Firm shall have a collection history of 5 plus years. D. Agency shall have current memberships with the Better Business Bureau, American Collectors Association, Inc., and/or the Missouri Collectors Association Inc. E. Recommendations or the name and contact information from three current clients should be included in the proposal. 3. Review Criteria Each proposal will be reviewed and evaluated using the following criteria: A. B. C. D. E.

Years of experience, and demonstrated ability to perform desired services Frequency of Status Reporting (ex. weekly, monthly, online) Proposed collection fees Collection Success Rate Reputation

III. SCOPE OF SERVICES The successful bidder shall be required to enter into a written contract with the City to provide services for the collection of delinquent payments owed to the City, containing provisions for the following items: 1. The successful Agency must operate in accordance with ethical collection practices, and comply with the Federal Fair Debt Collection Practices Act under 15 U.S.C. sec. 1692 et. seq., the Telephone Consumer Protection Act, 47 U.S.C. 227, and the Automatic Stay in Bankruptcy, 11 U.S.C. 362, along with all other applicable state and federal laws and regulations, and city ordinances related to the transferred debt. 2. The Agency shall not initiate legal proceedings on an account without prior authorization by the City. All attorney fees, court costs, and other expenses incurred with legal collection proceedings authorized by the City shall be borne by the agency. 3. The City shall pay no fee for the Agency when the balance due has been reduced resulting from City action such as application of refund, security deposit or credit adjustment. Also, no fee will be paid based upon a collection resulting from the City receiving payment due to a customer refinancing or selling their home when a lien of any amount was in place. 4. The Agency shall accept accounts placed by the City under terms of this agreement and will use its best efforts to collect said accounts utilizing means legal, necessary and proper. It is understood that the City may second‐place accounts. 5. The City plans to place delinquent accounts immediately. Other accounts may be placed throughout the calendar year. The number of accounts referred to the Agency shall be solely within the discretion of the City. Further, the City shall make its own efforts at collection and written demands prior to turnover and will inform the debtor of the consequences of his/her failure to make payments. 6. The Agency shall retain individual accounts for a maximum of twelve (12) months per account. After an individual account has been retained by collection service for said twelve month period, collection service shall return said account to the City, unless an extension is granted by the City. Accounts set up on payment arrangements may be retained beyond a twelve-month period of time if payments are due to run beyond that point. The Agency shall notify the City of individual

accounts that have relocated with a City of Warrensburg address during the twelve month period. 7. The Agency agrees to return to the City, at no charge, accounts referred by mistake. The City will not knowingly refer any accounts where the account is serving on active duty in the United States Armed Forces, VISTA or Peace Corps, or under bankruptcy. 8. All data made available to the Agency by the City are and remain the property of the City and must be treated as confidential information. All listings, which may reveal names or identification number of individuals or employees, etc., if not returned to the City, must be properly destroyed so as to keep such information confidential. 9. Reporting Requirements: The successful Agency will be required to submit to the City regular monthly statements of debts collected in the previous month (month of collection) no later than thirty (30) days following the month of collection. 10. The Agency service shall not, under any circumstance, use any threats, intimidation, or harassment of the debtor in the collection of said accounts; nor shall collection service violate any guidelines as established by the Federal Trade Commission, Federal Communications Commission, nor shall the Agency violate any local, state, or federal laws. The City reserves the right to add further restrictions under this section upon written notification.

PLEASE MARK YOUR SUBMITTAL

“COLLECTION AGENCY SERVICES” AND SEND IT TO: City of Warrensburg Attention: Cindy Gabel, City Clerk 102 South Holden Street Warrensburg, Missouri 64093 660-747-9131 The City reserves the right to reject any and all proposals, to waive technical defects, and to select the proposal(s) deemed most advantageous to the City. The undersigned certifies that he/she has the authority to bind this company in an agreement to supply the service or commodity in accordance with all terms and conditions specified herein. Please type or print the information below. Company Name

Authorized Person (Print)

Address

Signature

City/State/Zip

Title

Telephone #

E-mail

Fax #

Date

Entity Type

Tax ID #

COLLECTION SERVICES AGREEMENT THIS AGREEMENT dated this ____ day of__________, 2015, by and between the City of Warrensburg, (herein "City") and ______________________(herein "Collection Agency"). IN CONSIDERATION OF the performance of the services rendered under this Agreement and payment for such services, the parties agree to the following: 1. Services - As authorized by the City in writing, the Collection Agency shall provide the City professional services for the benefit of the City as set forth in the Proposal and Scope of Work submitted by Collection Agency and accepted by City, and the Collection Agency shall provide the City, as applicable, with the services, reports, and other work outlined. Collection Agency agrees to provide all such services in a timely manner as established by the City in writing for each assigned project, or in the absence of the designation, within a reasonable time after receipt of City directives. Collection Agency agrees to provide services by and through qualified personnel under standards and conditions generally accepted by professionals in the field or occupations for which services are provided. Services shall be provided based only upon the Scope of Services described or by any additional proposals provided to the Collection Agency by the City or City's representative a written proposal for services which is approved by the City in writing. No work shall be performed nor shall compensation be paid for Collection Agency work performed without a City approved written proposal for professional services. Proposals for additional services shall be in written form and shall be specifically responsive to the criteria provided by the City. All work performed by the Collection Agency, based upon City approved proposals submitted by the Collection Agency, shall be subject to the terms and conditions of this agreement unless otherwise specifically agreed upon by the City and Collection Agency in writing. All proposals for work submitted by the Collection Agency to the City for work shall at a minimum contain the following: 1.1 Scope of Services - Collection Agency will provide the City with services as outlined in the City's initial request for proposals, and Collection Agency's response to that request, which are each incorporated herein. To the extent of any inconsistency, the terms of this Contract shall control, followed by the terms of the request for proposals, and then Collection Agency's response. Each proposal for services shall contain a detailed description of work to be performed by the Collection Agency. When the City provides the Collection Agency with a written and/or graphic request for proposal, the Collection Agency's proposal shall be responsive to the request with the same or greater level of specificity required by the request for proposal. The Collection Agency shall specifically identify services which are included as basic services and those services which are excluded from basic services in the proposal. Services which the Collection Agency does not identify as excluded from 1

basic services under the proposal and which are necessary for successful completion of the work in the judgment of the City shall be presumed to be a part of basic services under the proposal. If a request for proposal requires the Collection Agency to provide optional services, the Collection Agency's proposal shall respond to the options requested, or provide reasons why the Collection Agency cannot provide or respond to the request for optional services. 1.2 Time for Completion – The term of this Contract shall be for a period of twelve months. City shall have the right to renew this contract for up to four additional twelve month periods. This Contract shall automatically renew for such twelve month renewal periods unless City notifies Collection Agency in writing of its intent not to renew prior to the renewal date. 1.4 Compensation – Collection Agency shall be compensated based upon the rates set forth in its proposal for services. Any additional scope of work will state the amount of compensation or basis for calculating such compensation. Each proposal for services shall state the basis of compensation on either: (1) an hourly fee plus expense basis with a statement of a maximum compensation to be charged, or, (2) a lump sum payment of compensation for all work to be performed, or, (3) a payment based upon unit prices. Proposals for compensation for an hourly fee plus expense basis shall provide detailed time and expense estimates to support a maximum contract amount to be charged and shall be consistent with the hourly rates, unit prices and reimbursement rates made a part of this agreement by reference in paragraph two (2) below. When the City or City's representative requests the Collection Agency to provide work on an hourly fee plus expense basis, the Collection Agency's proposal shall be responsive to the request and shall not propose payment on another basis unless otherwise authorized. Unit price proposals shall identify and estimate the quantity of units as a part of the proposal when they can be identified and estimated, or as necessary in response to a particular request for proposal requesting such information. Each proposal for services shall also state a proposed payment schedule at a frequency no greater than monthly in such amounts as are consistent with amount of work to be performed and billed. Reimbursable expenses proposed shall be specifically identified and estimated as a part of the proposal with a statement of the maximum amount to be charged unless the City's request for proposal specifies otherwise. 1.5 Signatures - Collection Agency proposals for services under this agreement shall be signed and dated by the Collection Agency or an authorized representative of the Collection Agency (as applicable), and shall be considered binding offers to contract open for acceptance by the City for an indefinite duration unless limited in the proposal or withdrawn prior to acceptance by the City. All proposals for services under this 2

agreement shall be on forms approved by the City; use of the signature block shown in this agreement on a proposal for services shall be considered an adequate signature block. In the absence of a City provided form, the signature block shall contain a signature line for the City of Warrensburg by the its City Manager and a signature line for attestation by the City Clerk. In addition, the signature block shall contain a line for insertion of the date the proposal is approved by the City. 1.6 Compliance with Laws. Collection Agency, and all its agents, representatives, and employees, shall comply with all applicable laws, including, without limitation, the Fair Debt Collection Practices Act, the Telephone Consumer Protection Act, and the provisions of 11 U.S.C. 362 of the Bankruptcy Code (The Automatic Stay). Collection Agency will indemnify and hold City and its representatives and insurers harmless from all damages and costs associated with its violation of applicable federal or state laws and regulations. 2. Compensation - In consideration for the Collection Agency's provision of services under this agreement, the City agrees to compensate the Collection Agency for services rendered in accordance with the hourly rates, unit prices and reimbursement rates for expenses set forth in the proposal for the project for which compensation is sought. No increases in the rates and charges set forth in the proposal shall be permitted without the written authorization of the City. Payments shall be made within thirty (30) days of receipt of invoice by the City. Invoices shall be submitted periodically as mutually agreed upon by the City and Collection Agency, or in the absence of such agreement, upon completion of the work constituting the task or project for which services are provided. Invoices for services on an hourly fee plus expense basis shall individually describe the task or project by name, show hours expended by classes of personnel in increments of not less than one-quarter hour and rates applied, as well as describe work performed during the invoice period; reimbursable expenses shall be itemized. Invoices for services performed on a unit price basis shall identify the task or project by name, identify and quantify units charged for services during the invoice period. Invoices for services on a lump sum basis shall identify the task or project by name and the invoiced amount. Periodic invoices shall not exceed the amounts permitted in the Collection Agency's proposal approved by the City. When periodic requests for payment are made, they shall only reflect charges for work already complete. City may retain ten percent (10%) of any partial payment pending final completion of the contract services to correct any deficiencies in performance. The City reserves the right to withhold payment for inadequately documented invoices until documented as required herein. The City further reserves the right to withhold payments for unperformed work or work not performed on a timely basis in accordance with the Collection Agency's proposal when delays in performance of services are not attributable to the City, or as a result of a billing dispute between the City and Collection Agency. No penalty shall be assessed to City for such amounts withheld until after any dispute is resolved in Collection Agency's favor. 3

3. City Responsibilities - City agrees to furnish Collection Agency with all current and available information for each task or project assigned to Collection Agency, along with any information necessitated by changes in work or services initiated by the City which may effect services rendered hereunder. Collection Agency shall notify City of all information it may require from City or other Collection Agencys and Contractors of City sufficiently in advance so as to avoid delay of the work to be completed by Collection Agency. 4. Coordination of Work and Work Product - Collection Agency shall coordinate all work with the City's designated representative for each task or project assigned to Collection Agency and submit to the City's representative all work product in written or graphic form (and in electronic form if requested) as applicable or required. All reports and other documents or materials submitted by or to the City shall be considered the property of the City. When available and requested by the City, work product shall be provided in electronic form at actual cost in media compatible for use with City software and equipment, and Adobe .pdf format shall be acceptable. 5.

Protection of Work, Property and Persons – [Intentionally omitted]

6. General Insurance Requirements - Collection Agency shall purchase and maintain such insurance as will protect if from claims set forth below which may arise out of, or result from the Collection Agency's work, whether such execution be by the Collection Agency, any subcontractor, or by anyone directly or indirectly employed by any of them, or by anyone whose acts any of them may be liable: 6.1 Workers Compensation - Claims under workmen's compensation, disability benefit and other similar employee benefit acts in amounts required by law. In case any class of employees engaged in hazardous work under this Agreement is not protected under the workmen's compensation statute, the Collection Agency shall provide adequate and suitable insurance for the protection of its employees not otherwise protected. 6.2 Bodily Injury - Claims for damages because of bodily injury, occupational sickness or disease, or death of employees in the amounts required by law. 6.3

[INTENTIONALLY OMITTED]

6.4 Third Person Bodily Injury - Claims for damages because of bodily injury, sickness or disease, or death of any person other than employees in the amount of at least $398,638.00 per person and $2,657,587.00 per occurrence, or such amounts as are annually listed as the governmental sovereign immunity waiver in section 537.610 4

RSMo, as annually adjusted. 6.5 Automobile Coverage - Claims for damages because of injuries to persons and property arising out of the operation of the following in the execution of projects: a) b) c)

Collection Agency's own automobiles and trucks, Hired automobiles and trucks, and Automobiles and trucks now owned by the Collection Agency.

The insurance shall cover the use of the above mentioned automobiles and trucks during the term of this Agreement. The minimum amounts of such insurance shall be the same as required for Public Liability and Property Damage Insurance. 6.6 Professional Liability - Claims for damages resulting from errors or omissions of the Collection Agency or its employees in the amount of at least $1,000,000.00 per occurrence or $2,000,000.00 aggregate. 6.7 Public Liability and Property Damage - Claims for damages because of damage to any property, building, or structure on or adjacent to the City's premises, or the injury to or destruction of property resulting from the Collection Agency's services in the amount of at least $398,638.00 per person and $2,657,587.00 per occurrence per occurrence, or such amounts as are annually listed as the governmental sovereign immunity waiver in section 537.610 RSMo, as annually adjusted. Certificates of Insurance acceptable to the City shall be filed with the City prior to the commencement of any work assigned under this Agreement. These certificates shall contain a provision that coverage afforded under the policies will not be cancelled unless at least fifteen (15) days prior WRITTEN NOTICE has been given to the City, and shall name the City as an additional insured by endorsement. 7. Indemnification - Failure of Collection Agency to obtain or maintain such insurance during this contract, or to provide proper proofs thereof upon request of the City, shall not diminish, waive or otherwise reduce the Collection Agency's obligations to maintain such insurance coverage and Collection Agency shall indemnify and hold the City and all its personnel harmless from and against any and all claims, damages, losses and expenses, including reasonable attorney's fees and litigation costs, arising out of or resulting from the performance of services, provided that any such claim, damage, loss or expenses, is caused in whole or in part by the negligent act, omission and or liability of the Collection Agency, its agents or employees. Further, Collection Agency shall hold City harmless from any failure by Collection Agency to complete their work in compliance with all applicable local, state and federal regulations. 5

8. Delegation and Subcontracting - Unless otherwise proposed and approved in the Collection Agency's proposal for services, the Collection Agency shall not delegate or subcontract any work to be performed by the Collection Agency under this agreement to any other person, business or entity without the express advance written approval of the City for such delegation or subcontract work. 9. Records - To the extent not otherwise transferred to the City's possession, Collection Agency agrees to retain and provide the City with reasonable access to all work product, records, papers and other documents involving transactions and work related to or performed under this agreement for a period of three (3) years after this agreement expires. 10. Additional Services - No compensation shall be paid for any service rendered by the Collection Agency considered an additional service beyond the scope of services approved by the City unless rendition of that service and expense thereof has been authorized in writing by the City in advance of performance of such service. Any additional services performed by the Collection Agency prior to such authorization by the City shall be deemed a part of basic services for work performed under an City approved proposal for services governed by this agreement, whether enumerated in this agreement or not, for which the Collection Agency shall be entitled to no additional compensation. 11. City Authorization -When the term City is used in this agreement, it shall mean the government of the City of Warrensburg, Missouri or the City of Warrensburg City Council, as the context requires. Authorization by the City shall mean written instruction from the City Council or the City Manager, or his designee. It is further understood and agreed that no person or party is authorized to bind the City to any proposed agreement for services under the auspices of this agreement without having obtained the prior approval of the City of Warrensburg City Council or City Manager, or his designee. In this regard, it is understood and agreed that the Collection Agency shall not be entitled to rely upon verbal representations by any agent or employee of the City in deviation to the terms and conditions of this agreement, or as authorization for compensation for services except as may be approved by the City Council or City Manager in writing. When the term City's representative is used, it shall mean the City Manager or his designee as specified in writing. 12. Period of Services and Termination – The term of this Contract shall be for a period of twelve months. City shall have the right to renew this contract for up to four additional twelve month periods. This Contract shall automatically renew for such twelve month renewal periods unless City notifies Collection Agency in writing of its intent not to renew prior to the renewal date. The City may and reserves the right to terminate this agreement at any time with or without cause by giving the Collection Agency written notice of termination. Upon receipt of

such notice, Collection Agency shall discontinue all services in connection with the performance of services authorized under this agreement or City approved proposal for services and City shall upon invoice remit payment for all authorized services completed up to the date of termination notice. Upon payment of this invoice, the Collection Agency shall deliver any and all work product including drawings, plans, and specifications, or other documents, prepared as instruments of service, whether complete or in progress. It is further agreed that if services are terminated the Collection Agency shall be compensated for all services rendered through the date of termination not to exceed the amount authorized for services through the date of termination. If the City questions the extent of work on a final invoice, the Collection Agency shall give the City the opportunity to review and evaluate all work upon which the invoice is based in the offices of the Collection Agency prior to payment. This agreement or work performed under the provisions of this agreement may also be terminated by the Collection Agency upon not less than seven days written notice in the event the City shall substantially fail to perform in accordance with the terms and conditions of this agreement, through no fault of the Collection Agency. In the event of termination by the Collection Agency, the other provisions concerning termination contained in this paragraph shall be applicable. 13. Governing Law - This agreement shall be governed by the laws of the state of Missouri and it is agreed that this agreement is made in Johnson County, Missouri and that Johnson County, Missouri is proper venue for any action pertaining to the interpretation or enforcement of any provision within or services performed under this agreement. 14. Certification of Lawful Presence / Work Authorization - Collection Agency will complete the required certifications of lawful presence and, if the contract is to exceed $5,000.00, shall complete and return the Work Authorization Certification attached hereto. Collection Agency shall indemnify and hold harmless the City and its officials, agents and employees from all costs and liabilities incurred as a result of Collection Agency’s failure, or failure of its employees, agents or Subcontractors, to comply with Section 285.530 RSMo regarding unauthorized aliens, and Section 208.009 RSMo regarding contracts with public entities. Attached hereto are certifications of compliance required. 15. Nature of Relationship - Collection Agency herein is an independent party and shall not act as an agent for the City, nor shall Collection Agency be deemed to be an employee of the City for any purposes whatsoever. The Collection Agency shall not enter into any agreement or incur any obligations on the City’s behalf or commit the City in any manner. 16. Miscellaneous - This agreement constitutes the entire agreement of the parties superseding all prior negotiations, written or verbal, and may only be amended by signed writing executed by the parties through their authorized representatives hereunder. 17.

Ownership of Documents – [Intentionally omitted]

18. Conflict of Interest - Collection Agency hereby covenants that at the time of the submission of any proposal and the execution of this Agreement it has no other contractual or employment relationships which would create any actual or perceived conflict of interest with the City. The Collection Agency further agrees that during the term of this Agreement neither the Collection Agency nor any of its employees shall acquire any other contractual relationships which create such a conflict. Collection Agency shall complete the required Conflict of Interest Form attached hereto and shall have an affirmative duty to update said form if there are any changes to the answers provided therein during the term of this Agreement.

IN WITNESS WHEREOF, the parties have executed this agreement by their duly authorized signatories effective the date and year first-above written. Collection Agency

CITY OF WARRENSBURG, MISSOURI

___________________________________ BY:________________________________ Position with firm:____________________ DATE:

____________________________________ Harold Stewart, City Manager DATE: ATTEST:

___________________________________ Cindy Gabel, City Clerk

CERTIFICATION OF INDIVIDUAL BIDDER Pursuant to Section 208.009 RSMo, any person applying for or receiving any grant, contract, loan, retirement, welfare, health benefit, post secondary education, scholarship, disability benefit, housing benefit or food assistance who is over 18 must verify their lawful presence in the United States. Please indicate compliance below. Note: A parent or guardian applying for a public benefit on behalf of a child who is citizen or permanent resident need not comply. _____1.

I have provided a copy of documents showing citizenship or lawful presence in the United States. (Such proof may be a Missouri driver’s license, U.S. passport, birth certificate, or immigration documents). Note: If the applicant is an alien, verification of lawful presence must occur prior to receiving a public benefit.

_____2.

I do not have the above documents, but provide an affidavit (copy attached) which may allow for temporary 90 day qualification.

_____3.

I have provided a completed application for a birth certificate pending in the State of _______________. Qualification shall terminate upon receipt of the birth certificate or determination that a birth certificate does not exist because I am not a United States citizen.

__________________________________ __________________________ Date Printed Name

Applicant

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AFFIDAVIT (Only Required for Individual Bidder Certification Option #2) State of Missouri County of ____________

) )SS. )

I, the undersigned, being at least eighteen years of age, swear upon my oath that I am either a United States citizen or am classified by the United States government as being lawfully admitted for permanent residence. ____________________ Date

_______________________________ Signature

______________________ Social Security Number or Other Federal I.D. Number

_______________________________ Printed Name

On the date above written ___________________ appeared before me and swore that the facts contained in the foregoing affidavit are true according to his/her best knowledge, information and belief. _______________________________ Notary Public My Commission Expires:

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WORK AUTHORIZATION CERTIFICATION PURSUANT TO 285.530 RSMo (FOR ALL AGREEMENTS IN EXCESS OF $5,000.00) County of __________ State of ___________

) )ss )

My name is ____________________. I am an authorized agent of __________ __________________(Bidder). This business is enrolled and participates in a federal work authorization program for all employees working in connection with services provided to the City. This business does not knowingly employ any person that is an unauthorized alien in connection with the services being provided. Documentation of participation in a federal work authorization program is attached hereto. Furthermore, all Subcontractors working on this contract shall affirmatively state in writing in their contracts that they are not in violation of Section 285.530.1, shall not thereafter be in violation and submit a sworn affidavit under penalty of perjury that all employees are lawfully present in the United States. __________________________________ Affiant Date __________________________________ Printed Name Subscribed and sworn to before me this ___ day of ___________, 20___. _______________________________ Notary Public

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CONFLICT OF INTEREST FORM PROJECT: __________________________________________________________________ RESPONSIBLE CITY EMPLOYEE: ______________________________________________ RESPONSIBLE OR SUPERVISING CITY CONSULTANT: ____________________________ 1. Have you or any employee or person holding an ownership interest in the company proposing to provide goods or services to the City of Warrensburg been involved in any of the following with the City of Warrensburg, its employees, elected officials or any responsible consultant identified above? Sale, purchase or exchange of property

Yes ______

No ______

Receiving or furnishing goods or services

______

______

Transfer or receipt of income, assets or funds

______

______

Maintenance of bank balances, book balances or other accounts for benefit of another?

______

______

2. Have you or any employee or person holding an ownership interest in the company proposing to provide goods or services to the City of Warrensburg been indebted to the City, any employee of the City or its elected officials or its responsible consultants in the last twenty-four months? If yes, explain. _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. List all business transactions or relationships that you or any employee or person holding an ownership interest in the company proposing to provide goods or services to the City of Warrensburg has had with any employee of the City, its elected official or its responsible consultants in the last twenty-four months. ______________________________________________________________________________ ______________________________________________________________________________

4. List all gifts valued in excess of $10.00 offered or accepted by any employee or person 12

holding an ownership interest in the company proposing to provide goods or services to the City of Warrensburg either to or from any employee, elected official or its responsible consultants in the last twenty-four months. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ By executing this disclosure form, the undersigned personally, and on behalf of the proposing business entity verifies that the information contained herein is truthful and accurate and will remain truthful and accurate throughout all business transactions with the City of Warrensburg. _______________________________ by: ____________________________ STATE OF MISSOURI COUNTY OF JOHNSON

Date: _____________________

) )SS. )

On this ____ day of ___________, 201__, before me, appeared _____________, to me personally known, who being duly sworn, did swear that the matters contained herein are true to his/her best knowledge and belief. IN WITNESS WHEREOF, I have placed my hand and notarial seal the day and year last above written. _____________________________________ NOTARY PUBLIC